Stress Questionnaire

This subjective questionnaire is will give your health care practitioner a quick summary of symptoms or signs that may be related to health. It is not a substitute for professional medical advice from your health care provider.

Do you frequently feel overwhelmed?*

Yes

No

Do you often feel "tired and wired"?*

Yes

No

Do you frequently feel drained?*

Yes

No

Do you have less energy than normal? *

Yes

No

Do you sometimes feel unhappy?*

Yes

No

Do you occasionally have trouble sleeping at night?*

Yes

No

Do you have difficulty in concentrating?*

Yes

No

Are you angered easily? *

Yes

No

Do you often rely on caffeine or nicotine to get through the day?*

Yes

No

Do you use medication (or alcohol) to cope with your stressful lifestyle? *